Collagen VI-Related Dystrophies

Excerpt

Clinical characteristics: Collagen VI-related dystrophies (COL6-RDs) represent a continuum of overlapping clinical phenotypes with Bethlem muscular dystrophy at the milder end, Ullrich congenital muscular dystrophy (UCMD) at the more severe end, and a phenotype in between UCMD and Bethlem muscular dystrophy, referred to as intermediate COL6-RD.

1. Bethlem muscular dystrophy is characterized by a combination of proximal muscle weakness and joint contractures. Hypotonia and delayed motor milestones occur in early childhood; mild hypotonia and weakness may be present congenitally. By adulthood, there is evidence of proximal weakness and contractures of the elbows, Achilles tendons, and long finger flexors. The progression of weakness is slow, and more than two thirds of affected individuals older than age 50 years remain independently ambulatory indoors, while relying on supportive means for mobility outdoors. Respiratory involvement is not a consistent feature.

2. UCMD is characterized by congenital weakness, hypotonia, proximal joint contractures, and striking hyperlaxity of distal joints. Decreased fetal movements are frequently reported. Some affected children acquire the ability to walk independently; however, progression of the disease results in a loss of ambulation by age ten to eleven years. Early and severe respiratory insufficiency occurs in all individuals, resulting in the need for nocturnal noninvasive ventilation (NIV) in the form of bilevel positive airway pressure (BiPAP) by age 11 years.

3. Intermediate COL6-RD is characterized by independent ambulation past age 11 years and respiratory insufficiency that is later in onset than in UCMD and results in the need for NIV in the form of BiPAP by the late teens to early 20s. In contrast to individuals with Bethlem muscular dystrophy, those with intermediate COL6-RD typically do not achieve the ability to run, jump, or climb stairs without use of a railing.

Diagnosis/testing: The diagnosis of a COL6-RD can be suspected in a proband with characteristic clinical features, muscle imaging features, and muscle immunohistochemical features. The diagnosis can be confirmed by identification of a heterozygous or biallelic pathogenic variant(s) in COL6A1, COL6A2, or COL6A3.

Management: Treatment of manifestations

1. Bethlem muscular dystrophy. BiPAP as needed to support nocturnal ventilation and prevent right heart strain; scoliosis treatment per orthopedics; if surgical treatment for scoliosis is needed, coordinate with orthopedics, anesthesia, intensive care, and pulmonary specialists; physical therapy and occupational therapy to provide recommendations for joint stretching, swimming, and aquatherapy; treatment of Achilles tendon contractures per orthopedist.

2. UCMD / intermediate COL6-RD. BiPAP to support ventilation and prevent right heart strain. Use of insufflator/exsufflator to promote airway clearance; treatment of scoliosis per orthopedist; if surgical treatment for scoliosis is needed, coordinate with orthopedics, anesthesia, intensive care, and pulmonary specialists; physical therapy and occupational therapy to provide recommendations for joint stretching, swimming, and aquatherapy; treatment of Achilles tendon contractures per orthopedist; feeding and nutrition support as needed for failure to thrive.

Surveillance

1. Bethlem muscular dystrophy. Respiratory surveillance including annual pulmonary function tests (PFTs) in the upright and supine positions and polysomnogram for assessing for nocturnal hypoventilation with BiPAP initiation and follow-up polysomnograms as needed; annual clinical and radiographic assessment of scoliosis; annual cardiac evaluation with echocardiogram and EKG; annual physical therapy and occupational therapy assessment of muscle weakness, joint contractures, and need for mobility devices.

2. UCMD / intermediate COL6-RD. Respiratory surveillance including PFTs in the upright and supine positions every six months and polysomnogram to assess for nocturnal hypoventilation for timely initiation of NIV in the form of BiPAP with follow-up polysomnograms every one to two years; annual clinical and radiographic assessment of scoliosis; annual cardiac evaluation with echocardiogram and EKG; physical therapy and occupational therapy assessments of muscle weakness, joint contractures, and need for mobility devices every six months; nutritional assessments every six months. Because respiratory insufficiency is a leading cause of failure to thrive, assessments of ventilation (with PFTs and polysomnogram) are essential as surveillance both for respiratory insufficiency and for failure to thrive.

Genetic counseling: The COL6-RDs can be inherited in an autosomal dominant or an autosomal recessive manner. Bethlem muscular dystrophy is usually inherited in an autosomal dominant manner, although autosomal recessive inheritance has also been reported. UCMD and intermediate COL6-RD are typically caused by a de novo autosomal dominant COL6A1, COL6A2, or COL6A3 pathogenic variant. Less commonly, UCMD and intermediate COL6-RD are inherited in an autosomal recessive manner. Parental somatic mosaicism (and concomitant germline mosaicism) is not uncommon in the autosomal dominant COL6-RDs.

1. Autosomal dominant. If a parent of the proband has the pathogenic variant identified in the proband and/or is affected, the risk to the sibs of inheriting the variant is 50%. The severity of COL6-RD manifestations may vary among family members who are heterozygous for the same pathogenic variant.

2. Autosomal recessive. If both parents are known to be heterozygous for a pathogenic variant, each sib of an affected individual has at conception a 25% chance of being affected, a 50% chance of being an asymptomatic carrier, and a 25% chance of being unaffected and not a carrier. Carrier testing for at-risk relatives requires prior identification of the COL6A1, COL6A2, or COL6A3 pathogenic variants in the family.

Once the COL6A1, COL6A2, or COL6A3 pathogenic variant(s) have been identified in an affected family member, prenatal testing for a pregnancy at increased risk and preimplantation genetic testing are possible.